Test #3 Structurally Induced Coma

Front 1

Monro-Kellie Hypothesis?

Back 1

an increase in vol of 1 of 3 components (brain, blood or CSF) will inc pressure (ICP) and decrease the vol of one of other components

Front 2

TBI?

Back 2

Traumatic Brain Injury: occurs when sudden trauma damages brain

Front 3

Describe 2 stages of brain injury?

Back 3

-Primary Injury: occurs at initial insult to head: burst blood vessel, contusion, stretching of axons
- Secondary injury: occurs as response to initial injury; causes cerebral edema & increased ICP; it's a complication of primaryinjury; nurse's goal is to prevent the secondary brain injury

Front 4

Name the 2 kinds of primary injury?

Back 4

- Open Head injury
- Closed Head injury

Front 5

Name the 4 kinds of open head injury?

Back 5

1) Open Fracture: have scalp laceration along w fracture, so risk of infection
2) Linear fracture: 80% of all fracture types; simple clean break; risk for arterial bleeding
3) Comminuted/Depressed: where bone is broken in several places or shattered creating numerous bone fragments: can tear dura mater and cause leaking of CSF so at risk for infection
4) Basilar skull fracture: @ base of skull, usually serious, cranial nerves could be affected; can also tear tympanic membrane

Front 6

Basilar skull fracture might not be visible on xray or CT because of location T or F

Back 6

T

Front 7

4 symptoms of Basilar Skull Fracture?

Back 7

1) Rhinorhea - nasal discharge; if fluid is clear you can dip for glucose; pos result means its CSF
2) Otorrhea - ear discharge
3) Raccoon eyes
4) Battle's Sign- bruising over mastoid process, right under ear

Front 8

what symptoms of a basilar skull fracture could indicate CSF leakage?

Back 8

Rhinorrhea &/or Ottorrhea; CSF leakage means tear in dura mater
- place gauze underneath to catch fluid, if CSF, then when it dries, should see halo sign (blood in center surrounded by serosnaguous ring)

Front 9

How to treat basilar skull fracture?

Back 9

- neuro checks
- look for meningitis if open fracture (infection of CSF)
- don't use NG tube or nasal suctioning with BSF since you could pierce brain; can only put tube in orally

Front 10

Closed head injury is a primary injury without a skull fracture.

Back 10

T; brain bounces around in head

Front 11

3 types of closed head injury (injury w/o skull fracture)?

Back 11

1) Concussion- transient disturbance of neurological function
2) Contusion- bruising of brain tissue at site of impact; can cause hemorrhage, edema, pt does not have to lose consciousness; requires CT for dx
3) Laceration- tears blood vessels; more serious than contusion

Front 12

In assessing closed head injury, what is most important assessment tool?

Back 12

Hx of what happened is most important
- what was force of impact
- what was direction of impact

Front 13

Only 10% of concussions cause loss of consciousness T or F

Back 13

T

Front 14

S & S of concussion?

Back 14

dizziness, HA, amnesia of event, loss of balance

Front 15

What should family member do for pt w concussion?

Back 15

- must stay w pt & wake them every 3-4 hrs for 2 days to check for worsening condition; must also ask pt pertinent q's ie, where are they, time, place

Front 16

Sport doctors recommend not playing the sport for 3 mo after concussion. Why?

Back 16

- Due to Post Concussion Syndrome
- can occur up to 2 yrs following concussion
- occurs after 1 hit, more serious after 2nd hit
- S & S: anxiety, irritability, difficulty w concentration, HA

Front 17

What is most important with head injury?

Back 17

Prevention

Front 18

50% of pts who die from traumatic brain injury die within ____ hrs

Back 18

1-2 hrs

Front 19

For head injury, what is
1) assessment
2) treatment

Back 19

1) oxygenation, BP, Glasgow Coma Scale, pupil exam
2) airway, oxygenation, fluids to maintain BP, surgery

Front 20

Hematoma?

Back 20

space occupying lesion; collection of blood

Front 21

Lesion?

Back 21

wound, injury or pathological change in body tissue

Front 22

Tumor?

Back 22

also space-occupying lesion

Front 23

List 3 secondary injuries (complications of primary brain injury)?

Back 23

1) Hypoxemia- tissue hypoxia causes dec PH, inc CO2
2) Hypercapnia -increased CO2 causes dilation of cerebral blood vessels (inc ICP)
3) Cerebral vasodilation - results in increased cerebral blood flow (inc ICP)

Front 24

Cerebral edema is caused by any extra fluid in skull, ie increased fluid content ( can be extracellular or cellular)
- cerebral edema, brain swelling, and inc ICP are used interchangeably
- brain swelling increases the size of brain tissue and decreases the size of the ventricles (can cause ICP)
- maximum swelling occurs ____ days after injury

Back 24

2-4 days

Front 25

Brain Ventricles?

Back 25

4 cavities within brain filled w CSF

Front 26

2 types of cerebral edema?

Back 26

1) Vasogenic cerebral edema: increased capillary permeability; it impairs blood/brain barrier making your brain more open to any toxins that go in body
2) Cytoxic Cerebral Edema: 02 gets depleted; metabolic wastes accumulate; cells die; increases ICP

Front 27

Hydrocephalus?

Back 27

type of secondary brain injury due to increased CSF vol caused by:
- increased production
- obstructed circulation
- decreased absorbtion
- body normally makes 18 ml/hr

Front 28

2 fluid imbalance problems encountered w TBI (traumatic brain injury)?

Back 28

1) Diabetes insipidus (low ADH)- causes polyuria(excessive urination)/polydipsia (excessive thirst) often seen w closed injury; caused by lesion affecting hypothalamus/pituitary
2) SIADH (High ADH) - Syndrome of inappropriate antidiuretic hormone- causes oliguria (low urination -less than 500ml/24 hrs)

Front 29

with increased ICP, skull can't expand, so 1 of 3 components must decrease
1- shift CSF
2- Dec cerebral blood flow
3- Displace brain tissue -causes herniation
- Herniation?

Back 29

where brain is forced out of skull
- displacement of brain tissue across tentorium or thru foramen magnum into spinal canal; often results in death

Front 30

3 common areas of herniations?

Back 30

- Falx Cerebri
- Tentorium Cerebelli
- Foramen Magnum

Front 31

With brain injury, pt loses blood/brain barrier and auto regulation. T or F

Back 31

T

Front 32

what 3 activities can increase ICP in brain injured pt?

Back 32

1- turning pt
2- suctioning pt
3- valsalva maneuver

Front 33

what is leading cause of death in head trauma?

Back 33

ICP

Front 34

what is 1st sign of ICP?

Back 34

Decreased LOC
- and ALOA; also decrease in Glasgow Coma Scale

Front 35

2nd sign of ICP?

Back 35

pupils change as nerves get compressed

Front 36

3rd sign of ICP?

Back 36

motor changes

Front 37

May see altered thermal regulation where body temperature increases to 105 even though no infection due to compression (ICP). T or F

Back 37

T

Front 38

what 6 things happen with ICP?

Back 38

1- cerebral vasodilation occurs
2- PH of brain is dec (acidotic)
3- cerebral blood flow dec
4- edema of brain
5- C02 is incr
6- Tissue hypoxia occurs

Front 39

Cushings Triad?

Back 39

- late sign of ICP; sign that herniation will occur w/in minutes
- 3 things occur:
1- inc SBP w widening pulse pressure
2- dec HR: bradycardia
3- dec RR

Front 40

ICP = Cushing's Triad T or F

Back 40

T

Front 41

Don't want brain to become hypoxic. Why?

Back 41

If C02 inc, blood vessels will dilate and any inc circ will cause brain edema/swelling, so need to provide 02.

Front 42

Goals of emergency care for pt at risk of dev ICP?

Back 42

optimize cerebral perfusion by:
1) maintaining airway
2) Improve breathing
3) promote circulation
- use CPP: continuous positive pressure breathing

Front 43

Glasgow Coma Scale?

Back 43

involves 3 areas: eye opening, verbal response, motor response
- score of 15 - no impairment
- score of 7 - coma
- score of 3- brain death

Front 44

ICP Monitoring ?
- Pts on ICP monitoring are at high risk of infection
- use catheter inserted through Burr Hole in skull into brain

Back 44

- allows continuous monitoring of ICP
- recommended for pts w GCS of 3-8 or if abnormal CT shows swelling or herniation

Front 45

Intraventricular catheter can be used to drain CSF and monitor ICP. T or F

Back 45

T

Front 46

Adv of ICP monitoring?

Back 46

- ICP can be recog & treated before symptoms appear
- allows drainage of CSF fluid via 3-way stopcock
- CPP can be calc & treatment adj
- effect of nursing interventions can be monitored

Front 47

MAP?

Back 47

Mean Arterial Pressure:
(SBP + 2DBP)/3

Front 48

CPP (blood flow) = MAP - ICP
- cerebral blood flow is dependent upon SPP ; treat to keep CPP 50-70;
CPP < ____ is incompatible with life
Normal CPP is_____

Back 48

- < 30 mm Hg
- 70-100 mm Hg

Front 49

To dec ICP, can implant surgical shunts, will be in pt for lifetime
- Types of shunts?

Back 49

VP Shunt: Ventricular Peritoneal Shunt

Front 50

Early ______ is recommended for pt with ALOA and impending ICP

Back 50

intubation

Front 51

A temporary method to reduce ICP?

Back 51

hyperventilate pt (via ventilator) to vasoconstrict blood vessels in brain; get PaC02 to 30-35 mm Hg
- don't do for prolonged period as it will cause ischemia

Front 52

What 2 meds reduce ICP?

Back 52

- Mannitol - osmotic diuretic - administered IV
- loop diuretics
- monitor serum osmolality and urine specific gravity

Front 53

Why use corticosteroids?

Back 53

not recommended for brain trauma, but used for tumors; also used to reduce edema
- neg: increases BG & increases risk for GI bleed and infection

Front 54

Pts w brain injury are put on ulcer prevention meds, ie Protonix, Zantac, Pepcid
- these pts are at risk for Curlings Ulcers - a duodenal ulcer that develops in people who have suffered severe stress. T or F

Back 54

T

Front 55

Why give antibiotics to brain injury pts?

Back 55

- used prophalactically in intubated pts to prevent infection
- needed if pt has open wound or if pt has ICP monitoring device.

Front 56

Why give antiseizure meds?

Back 56

put on prophalactically for pts who undergo high risk procedures

Front 57

Why give nimodipine to brain injury pts?

Back 57

- Ca Ch Blocker used to treat vasospasms (blood vessels constrict and close) since relaxes smooth muscles
- vasospasms can occur with hemorrhage where the blood can irritate blood vessels and cause vasospasms

Front 58

Why give Amicar (Aminocaproic Acid)?

Back 58

- helps blood clot; the opposite of thrombolytics

Front 59

- Pts w ischemic strokes get ____ to open blood vessels
- Pts with bleeding get ___ to stabilize blood vessel

Back 59

- thrombolytics
- Amicar

Front 60

Propofol is given w _______

Back 60

mechanical ventilation; used for conscious sedation; sedative hypnotic

Front 61

Why give Pentobarbitol IV (barbiturate) to brain injured pts?

Back 61

- used for refractory ICP ie, when docs don't know what else to do
- dec metabolic rate & cerebral metabolism
- pt on this med is in a "drug induced coma"
- have to have arterial line for continuous BP measurements
- have to be on ventilator & cardiac monitoring

Front 62

What is negative about giving anesthetics, analgesics, and sedatives?

Back 62

these meds obscure neuro checks
- common practice is to taper the meds every 4 hrs, do neuro checks, and then continue meds

Front 63

Prophylactic Hypothermia?

Back 63

- bring pt temp below 90 F
- assoc w higher GCS score vs normal therm pts

Front 64

Nursing Mgmt of ALOA
- P: disturbed thought processes
- E: Bowel/urinary incontinence- use foley & monitor I&O
- R: Impaired physical mobility- DVT prevention, compression boots and/or heparin
- S: seizures: treat for hyperthermia w temps 105-108 F via cooling blanket; Tylenol won't help
-O: impaired gas xchange- support ventilation w mech ventilation
-N: Risk for nutrition imbalance: risk for electrolyte imbalance; begin w/in 72 hrs

Back 64

T

Front 65

- ______ & ____ are meds of choice for pain as they don't obscure pupil check;
- With ____ , the pupils get smaller

Back 65

- Fentanyl & Codeine
- Morphine

Front 66

If low urine output and urine specific gravity is high (>1.025), this could be sign of ____; don't have meds to treat this but put pt on fluid restriction and give hypertonic saline (3%)

Back 66

SIADH (Syndrome of Inappropriate Anti Diuretic Hormone secretion)

Front 67

If high urine output and low urine specific gravity < 1.005, suspect ______ which puts pt at risk for hypovolemic shock; give vasopressin (ADH) to treat (give subq, not IV)

Back 67

Diabetic Insipidus

Front 68

Promote venous return from jugular veins by elevating HOB to 30-45 degrees; avoid flexing or extending neck, neck sh be in neutral posture

Back 68

T

Front 69

brain injured pts sh always be log-rolled to decrease vagal maneuver which can increase ICP;

Back 69

T

Front 70

Purpose of Craniotomy?

Back 70

- to relieve pressure on brain
- or to evacuate hematoma or clip aneurysm

Front 71

Craniectomy?

Back 71

remove depressed skull fracture

Front 72

Pre-Op care for craniotomy?

Back 72

before surgery do baseline physical and neuro assessment

Front 73

Post-Op care for craniotomy?

Back 73

- do frequent neuro checks to look for subtle changes in mental status, LOC, cranial nerve compression as S&S of ICP, bleeding
- space out nursing activities to avoid inc ICP: suction only when needed
- manage pain

Front 74

Tentorium?
- With supratentorial surgery (above tentorium) must elevate HOB 30 degrees
- With infratentorial surgery (below tentorium) HOB is flat

Back 74

Cerebellum & brain stem area